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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1036678



Case Details

VAERS ID: 1036678 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-02-14
Onset:2021-02-16
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL9264 / 2 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardiac failure, Death, End stage renal disease, Unresponsive to stimuli
SMQs:, Rhabdomyolysis/myopathy (broad), Cardiac failure (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-16
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine bes 5 mg ta 1 tab q am, baclofen 10 mg tab ? q am and pm, carvedilol 25 mg 1 tab q am and pm, clonidine hcl 0.3 mg tab q morning, afternoon and evening, escitalopram 20 mg 1 tab q am, floranex tab by mouth 3 times weekly, hydral
Current Illness: pneumonia-recent infection
Preexisting Conditions: chronic kidney disease-stage 4, schizophrenia, heart disease, COPD, hypertensive heart disease with heart failure, myalgia, nonrheumatic aortic valve stenosis
Allergies: hydantoins, lipitor, phenytoin, statins-hmg-coa, reductase inhibitors
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident did not exhibit any side effects from the vaccine. Staff spoke with him in his room at approximately 7:20am and returned to his room just a few minutes later and he was unresponsive. When the RN got to the room he had CTB. Physician documented heart failure and end stage kidney disease on the death certificate.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1036678

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